Study design and settings
This was a retrospective review of severe malaria cases admitted from 1st January to 31st December 2019, otherwise referred to as the pre-COVID-19 period and January 1st to 31st December (COVID-19 period) at Federal Teaching Hospital, Katsina, Nigeria. The hospital is a 700-bed tertiary health facility located in north-western Nigeria and receives referrals within the state, parts of adjoining states, and the Niger republic. This study took place in the emergency and pediatric wards of the hospital. The hospital has a dedicated COVID-19 isolation and treatment center, which is separate from other hospital structures including the pediatric wards. In addition, during the peak of the first wave of COVID-19 in Nigeria, the hospital remained open including the pediatric units and ensured minimal disruption of services.
Study population
This study involved children aged 14 years and below with the diagnosis of severe malaria during the study period (1st of January 2019 to 31st December 2020).
Case definition for severe malaria
The definition of severe malaria was based on the world health organization (WHO) guidelines for severe malaria (2015).[17] In brief, a case of severe malaria was defined as evidence of parasitological confirmation and presence of life threatening features, which include any of the following: “impaired consciousness” defined as Glasgow score of less than 11 or Blantyre coma score less than 3 for younger children; “prostration” defined as generalized weakness (a child was unable to sit, stand or walk without assistance); “ multiple convulsions referred to a child with more than two episodes of convulsion within 24 hours; “acidosis” was defined as a plasma bicarbonate level of less than 15 mmol/l and severe acidosis in the presence of respiratory distress characterised by rapid, deep, and laboured breathing; “hypoglycaemia” referred to blood or plasma glucose of less than 2.2 mmol while “severe anaemia” was defined as haemoglobin concentration less than or equal 5 g/dl or packed cell volume of less than or equal to 15% in children <12 years of age and less than 7 g/dl or packed cell volume of 20% in those aged 12 years; “acute kidney injury” was defined as plasma or serum creatinine 3 mg/dl or blood urea >20 mmol/l while “jaundice” was defined as the plasma or serum bilirubin >50 umol/l or 3 mg/dl; “pulmonary oedema” was defined as radiologically confirmed or oxygen saturation <92% on room air with a respiratory rate greater than 30/minute, or age appropriate tachypnoea often with chest indrawing and crepitations on auscultation; “significant bleeding” referred to recurrent or prolonged bleeding from the nose, gums or venepuncture sites; hematemesis or melena; “Compensated shock” was defined as capillary refill greater or equal three seconds but no hypotension, and “decompensated shock” was defined as systolic blood pressure <70 mm Hg with evidence of impaired perfusion (cool peripheries or prolonged capillary refill). “Hyperparasitaemia” was defined as plasmodium falciparum parasitemia>10%.
The parasitological confirmation in this study was based on the child being tested positive with ‘rapid diagnostic test (RDT)’ kits and or the presence of malaria parasites on light microscopy.
Period of study
The pre-COVID-19 period spanned 1st January to 31st December 2020 COVID-19 period spanned 1st January to 31st December 2020 as the first case of COVID-19 was confirmed on the 27th February 2020 in Nigeria.[18]
Sample size
The sample size for this study included all the children admitted with severe malaria between the 1st of January 2019 and the 31st of December 2020.
Inclusion criteria
We included children with parasitological confirmed severe malaria.
Exclusion criteria
We excluded the following children from the study: children less than three months; the presence of comorbidities such as sickle cell disease, chronic kidney disease; and those with underlying severe acute malnutrition.
Outcomes measured.
The primary outcomes of this study were to determine and compare the prevalence and hospitalization outcomes (length of stay from day of admission, deaths, or discharge) between pre-COVID-19 and COVID-19 periods among children with severe malaria. The secondary outcomes were to describe and compare the profile and index of severity of severe malaria between the two periods.
Data extraction
The data of children with severe malaria admitted from 1st January 2019 to 31st December 2020 were extracted from the electronic health records. Variables extracted included the age, sex, duration of symptoms before presentation at our health facility, duration of hospitalization, forms of severe malaria, date of admission, date of outcomes of hospitalization, and outcomes of hospitalization (defined as death or discharged).
Data analysis
The data were entered into an Excel spreadsheet and exported into SPSS version 25 for analysis. The age, duration of symptoms, and length of hospitalization were not normally distributed and were summarised as median with an interquartile range. In addition, the three variables were compared using Mann-Witney U between the pre-COVID-19 and COVID-19 periods. The discrete variables such as features of severe malaria, sex, and hospitalization outcomes were summarised using frequency tables and compared using Chi-square. In addition, the degree of association or otherwise was expressed as an odds ratio with a 95% confidence interval. The p-value was set at < 0.05 for all the statistical tests.